Development and validation of an evidence based educational program for adults undergoing anterior cruciate ligament reconstruction surgery in the United Arab Emirates

Hele tekst

(1)

(2) Declaration By submitting this thesis electronically, I declare that the entirety of the work contained therein is my own, original work, that I am the owner of the copyright thereof (unless to the extent explicitly otherwise stated) and that I have not previously in its entirety or in part submitted it for obtaining any qualification.. March 2010. Copyright © 2010 Stellenbosch University. All rights reserved.

(3) ABSTRACT BACKGROUND: Patients’ knowledge about the effectiveness of interventions is now recognized as an important facilitator of the implementation of evidence in practice. Evidence-based, patient education programs aim to impart knowledge about the efficacy and effectiveness about interventions to individuals. However, there is currently a lack of structured evidence-based educational programs to educate patients about the evidence-base for interventions prescribed by the health professionals in the field of orthopaedics. OBJECTIVE: The main objective of this study was to develop and validate an Arabic version of an evidence-based educational program for patients who are scheduled to undergo ACL reconstruction surgery in UAE, based on available evidence collated through a systematic review process. METHODS:. A. systematic. review. was. conducted. to. generate. clinical. recommendations which were used to develop the evidence-based educational program. The evidence-based information was derived from secondary research to determine which rehabilitation strategies were most effective in improving outcome measurements following ACL reconstruction surgery. A pre-final draft of the evidence-based educational program was prepared and forward and back translated from English into the Arabic language. Feedback groups of ACL patients and physiotherapists were used to determine the content and face validity of the program. The final draft was validated in a group of 40 ACL patients waiting to undergo ACL reconstruction surgery at Zayed Military hospital and Abu Dhabi Knee and Sports Medicine Centre in the UAE, using checklists. RESULTS: A total of 40 patients undergoing ACL reconstruction surgery consented to participate in this study. All the subjects were male. The age range was between 18 to 38 years old with mean age of 28.5 years (SD 5.75). Most of the patients (65%) underwent ACL reconstruction surgery to the right knee. Of the total sample (n=40), the majority of the subjects who participated in this study (90 %), had ACL surgery for the first time. Most of the responses to the evidence-based educational program checklist were positive. iii.

(4) CONCLUSION: It can be recommended that the newly-developed evidence-based educational program is a valid tool which can be given to ACL patients prior to ACL reconstruction to prepare them for the rehabilitation postoperatively. By informing patients of their condition, the expected outcomes of their condition and the effect of doing exercises to improve their condition, the patients will be more encouraged to partake in rehabilitation, as they know it is for their own good. This will ultimately improve overall patient care and improve management of ACL patients. Key words: Anterior cruciate ligament, educational program, evidence-based, validity. iv.

(5) DEDICATION This thesis is dedicated to my family.. v.

(6) ACKNOWLEDGEMENTS I hereby wish to extend my sincere gratitude to the following parties:. • The subjects who consented to participate in this study. Without them, this study would not have been possible.. • The physiotherapists who participated in this study. • Dr Brown and Dr Darwich for their support. • Prof Q Louw and Mrs L Crous for their support and guidance during this study.. • Mrs L Morris for her assistance during this study.. vi.

(7) INDEX. Page. Glossary. 1. List of tables, figure and addendums. 2. CHAPTER 1: Introduction. 4. CHAPTER 2: Phase 1- Systematic review 2.1 Background and rationale for assessment. 7. 2.2 Project aim. 8. 2.3 Research question. 8. 2.4 Objectives. 9. 2.5 Definitions. 10. 2.6 Methods of review. 10. 2.6.1 Criteria for considering studies. 10. 2.6.1.1 Types of studies. 10. 2.6.1.2 Types of participants. 11. 2.6.1.3 Types of interventions. 11. 2.6.1.4 Types of comparisons. 11. 2.6.1.5 Types of outcome measures. 11. 2.6.2 Search strategy for identification of studies. 12. 2.6.3 Level of evidence allocation. 13. 2.6.4 Assessment of methodological quality. 13. 2.6.5 Data storage. 14. 2.6.6 Data extraction. 14. 2.6.7 Data synthesis. 14. 2.7 Results. 14. 2.7.1 Search results. 14. 2.7.2 Level of evidence. 17. 2.7.3 Methodological appraisal. 17. 2.7.4 General description of studies. 18. 2.7.5 Outcome measures in included systematic reviews. 21. 2.7.6 Interventions. 22. 2.7.6.1 Exercise therapies. 22. 2.7.6.2 Cryotherapy. vii. 38.

(8) 2.7.6.3 Prevention of ACL injury. 39. 2.8 Summary points. 42. CHAPTER 3: Phase 2- Development and validation of evidence-based educational program 3.1 Introduction. 46. 3.2 Study aim. 46. 3.3 Study objectives. 46. 3.4 Methods. 47. 3.4.1 Development of evidence-based educational program. 47. 3.4.1.1 Generation of educational program evidence-based content. 47. 3.4.1.2 Translation process. 47. 3.4.1.3 Educational program development. 48. 3.4.1.4 Design of educational program booklet. 48. 3.4.1.5 Printing of educational program booklet. 49. 3.4.2 Content and face validation of pre-final evidence-based educational program booklet. 51. 3.4.2.1 A-Validation process among physiotherapist. 51. 3.4.2.1.1 Study aim. 51. 3.4.2.1.2 Study objectives. 51. 3.4.2.1.3 Study design. 52. 3.4.2.1.4 Study setting. 52. 3.4.2.1.5 Sample description. 52. 3.4.2.1.6 Sampling procedure and sample size. 53. 3.4.2.1.7 Interview question design. 53. 3.4.2.1.8 Study procedure. 54. 3.4.2.1.9 Data collection. 55. 3.4.2.1.10 Data transcription. 56. 3.4.2.1.11 Data validation. 56. 3.4.2.1.12 Data analysis. 56. 3.4.2.1.13 Results. 56. 3.4.2.1.14 Changes made to pre-final version. 59. 3.4.2.2 B: Validation process among patients. 59. 3.4.2.2.1 Study aim. 59. 3.4.2.2.2 Study objectives. 59 viii.

(9) 3.4.2.2.3 Study design. 60. 3.4.2.2.4 Study setting. 60. 3.4.2.2.5 Sample description. 60. 3.4.2.2.6 Sampling procedure and sample size. 60. 3.4.2.2.7 Interview question design. 60. 3.4.2.2.8 Study procedure. 61. 3.4.2.2.9 Data collection. 61. 3.4.2.2.10 Data transcription. 62. 3.4.2.2.11 Data validation. 62. 3.4.2.2.12 Data analysis. 62. 3.4.2.2.13 Results. 63. 3.4.2.2.14 Changes made to pre-final version. 65. 3.4.3 Pilot study: Pre-testing the pre-final version of the newly developed evidence-based educational program 3.4.3.1 Study aim. 66. 3.4.3. 2 Study objectives. 66. 3.4.3.3 Study setting. 66. 3.4.3.4 Sampling procedure and sample size. 67. 3.4.3.5 Sample description. 67. 3.4.3.6 Study procedure. 67. 3.4.3.7 Feedback sessions. 67. 3.4.3.8 Results. 68. 3.4.3.9 Outcomes of pilot study. 70. 3.5 Summary points of chapter. 71. CHAPTER 4: Phase 3: Validation of evidence-based educational program 4.1 Introduction. 72. 4.2 Research question. 72. 4.3 Study objectives. 72. 4.4 Methods. 72. 4.4.1 Study design. 72. 4.4.2 Study Setting. 72. 4.4.3 Sampling procedure and sample size. 73. 4.4.4 Sample description. 73. 4.4.5 Final version of educational program ix. 73.

(10) 4.4.6 Measurement tool. 74. 4.4.6.1 Development of checklist to validate educational program. 74. 4.4.7 Researchers responsibilities. 74. 4.4.8 Clinician’s responsibilities. 74. 4.4.9 Data collection procedure. 74. 4.4.10 Feedback sessions. 75. 4.5 Ethical considerations. 75. 4.6 Data analysis. 75. 4.7 Results. 76. 4.8 Summary points of chapter. 76. CHAPTER 5: Discussion, limitations, recommendations and conclusion 5.1 Discussion. 80. 5.2 Limitations. 85. 5.3 Recommendations. 86. 5.4 Clinical applications. 87. 5.5 Conclusion. 87. REFERENCES. 88. APPENDICES Appendix 1: Letter to Zayed Military Hospital and Abu Dhabi Knee and Sport Medicine Center. 91. Appendix 2 Letter from – A: Zayed Military Hospital. 92. B: Abu Dhabi knee and sport medicine centre. 93. Appendix 3 Patient Informed consent form (English and Arabic language). 94. Appendix 4 Interview questions for focus group of physiotherapist. 99. Appendix 5 Checklist for ACL reconstruction patients (checklist in English and Arabic) 100 Appendix 6 An evidence-based educational program booklet among ACL reconstruction patients (English). 102 x.

(11) GLOSSARY ABBREVIATIONS ACL:. Anterior Cruciate Ligament. UAE:. United Arab Emirates. ZMH:. Zayed Military Hospital. ADKSMC:. Abu Dhabi Knee and Sport Medicine Centre. FGFS:. Focus Group Feedback Session. DEFINITIONS Content validity Content validity is the degree to which the items in a measurement instrument adequately reflects the content domain being measured (Portney et al 2000). Face validity The assumption that the validity of an instrument is a reasonable measure of a given variable based on its appearance (Portney et al 2000). 1.

(12) LIST OF TABLES, FIGURES and ADDENDUMS TABLES. page. Chapter 2 2.1 JBI scale for level of evidence. 13. 2.2 Level of evidence results using the JBI scale. 17. 2.3 Methodological quality results of included systematic reviews. 18. 2.4 General description of included studies. 20. 2.5 Outcomes measured in included systematic reviews. 21. 2.6 Land-based versus water-based exercises. 23. 2.7 Supervised versus home-based exercises. 26. 2.8 Open kinematic chain versus closed kinematic chain exercises. 29. 2.9 Immediate versus late weight bearing exercises. 30. 2.10 AP laxity pre-operatively. 33. 2.11 Neuromuscular versus strength training. 34. 2.12 Other specific exercises. 37. 2.13 Cryotherapy. 39. 2.14 Prevention of ACL injury. 41. Chapter 3 3.1 Interview guide for focus groups of physiotherapists and patients. 54. 3.2 Results of interview questions of focus group of physiotherapists. 57. 3.3 Comments of focus group of physiotherapists. 58. 3.4 Demographic information of focus group of physiotherapists. 58. 3.5 Results of interview questions of focus group of patients. 64. 3.6 Comments of focus group of patients. 65. 3.7 Demographic information of focus group of physiotherapists. 65. 3.8 Checklist questions. 68. 3.9 Checklist responses. 70. 3.10 Pilot study scoring. 71. Chapter 4 4.1 Summary of comments made by subjects. 2. 78.

(13) FIGURES Chapter 1 1.1 Flow chart depicting project outline. 6. Chapter 2 2.1 Database search results. 16. 2.2 Summary of post-ACL reconstruction rehabilitation interventions. 22. Chapter 3 3.1 Flow chart depicting method of Chapter 3. 50. Chapter 4 4.1 Distribution of affected knee side amongst subjects. 76. 4.2 Distribution of total number of ACL surgeries per subject. 77. 4.3 Percentage of positive and negative responses for checklist questions 78 ADDENDUMS Chapter 2 2.A Search strategies. 44. 2.B Greenhalgh’s critical appraisal tool. 45. 3.

(14) CHAPTER 1 Introduction The role of the anterior cruciate ligament (ACL) in knee joint stability is critical (Zantop et al 2006). The ACL controls movement of the tibia relative to the femur and guides knee extension (Trees et al 2009). The ACL’s primary function is to prevent anterior translation and rotation of the tibia relative to the femur (Trees et al 2009). It also guides the screwhome mechanism associated with knee extension; prevents hyperextension and assists in prevention of varus and valgus movement, especially in the extended knee (Trees et al 2007). The multi-dimensional stability offered by the ACL, therefore contributes significantly to optimal knee function. The ACL’s multi-dimensional knee stability function is possible due to the structural arrangement of the ACL’s functional fiber bundles (Zantop et al 2006). Due to this fiber arrangement, the ACL is arguably one of the most complex ligaments in the human body (Zantop et al 2006). Injury to any of the functional fiber bundles leads to catastrophic functional implications for the lower limb, which necessitates surgical intervention (Zantop et al 2006). The aim of ACL surgical reconstruction techniques is to restore the static and dynamic joint stability of the injured knee comparable to that of the intact knee (Zantop et al 2006). It has been demonstrated that reconstruction of the ACL is successful in limiting anterior tibial translation (Zantop et al 2006). However, rotational stability of the surgical grafts is insufficient (Zantop et al 2006). Consequently, individuals who have undergone ACL reconstruction may still experience functional knee instability (Zantop et al 2006). Therefore, exercise rehabilitation strategies are crucial to address redundant knee functional instability post-surgery (McDonald et al 2007). Evidence-based exercise strategies to manage ACL injuries are therefore required to optimize knee function postsurgery and prevent the development of secondary osteoarthritic changes. Rehabilitation following ACL reconstruction typically commences during the acute inpatient period (McDonald et al 2007). The goals of post-operative ACL rehabilitation include controlling pain and swelling, restoration of knee range of motion, muscle strength and neuromuscular control to enable optimal function (McDonald et al 2007). The efficacy of a range of exercise strategies and approaches including land- and water based exercises, supervised and home-based exercise programs, open- and closed kinetic chain 4.

(15) exercises, weight-bearing exercises, neuromuscular and isokinetic strength training exercises has been established in randomized controlled trials (Trees et al 2009). However, the application of evidence-based rehabilitation strategies in clinical practice continues to be hampered by a lack of knowledge regarding the evidence for interventions by patients, as well as patient compliance to exercise programs during the post-operative stage. The role of patient education in the translation of research evidence into clinical practice has recently been highlighted. Patients’ knowledge about the effectiveness of interventions is now recognized as an important facilitator of the implementation of evidence in practice (Straus et al 2008). Evidence-based, patient education programs aim to impart knowledge about the efficacy and effectiveness about interventions to individuals. The health care recipient is thus empowered to play an active role in promoting the application of evidence-based health care in clinical practice (Osborne et al 2006). However, there is currently a lack of structured evidence-based educational programs to educate patients about the evidence-base for interventions prescribed by the health professionals in the field of orthopaedics. This study reports on the development and validation of the first evidence-based educational program to inform patients undergoing ACL reconstruction about the evidence of the most common post-ACL reconstruction rehabilitation interventions to be delivered by the health professional. The organization of the thesis chapters is illustrated in the flow chart (Figure 1.1).. 5.

(16) CHAPTER 1 Introduction. CHAPTER 2 PHASE 1: Systematic review of the available evidence for the effectiveness of various exercise therapies and cryotherapy on functional-related outcome measures during early and late phases of rehabilitation following ACL reconstruction in adults OUTCOME: The generation of evidence-based information to design an evidence-based educational program for ACL patients. CHAPTER 3 PHASE 2: Development of the evidence-based educational program for ACL patients OUTCOME: Develop a draft educational program. Initial validation of the newly-developed evidence-based educational program OUTCOME: Final evidence-based educational program developed. CHAPTER 4 PHASE 3: Further validation of the final evidence-based educational program OUTCOME: To determine the face and content validity of the Arabic evidence-based educational program booklet among patients who have sustained an ACL injury and were scheduled to undergo ACL reconstruction surgery. CHAPTER 5 Discussion, Limitations, recommendations and clinical applications Figure 1.1 Flow chart depicting project outline. 6.

(17) CHAPTER 2 Phase 1: Systematic review of the efficacy of various exercise therapies and cryotherapy on functional-related outcome measures during early and late phases of rehabilitation following anterior cruciate ligament reconstruction in adults. 2.1 BACKGROUND AND RATIONALE FOR ASSESSMENT Anterior Cruciate Ligament (ACL) tears are one of the most common and most serious knee ligament injuries (Demirag et al 2004), causing severe functional problems (Risberg et al 2007). More than 100,000 new ACL tears occur in the United States of America (USA) annually (Trees et al 2007) with the majority of cases reported in the young athlete population due to non-contact sports (Trees et al 2007). Following injury to the ACL, pain and inflammation may lead to muscle inhibition and the ability to fully activate the thigh muscles, may further result in muscle atrophy and consequently joint instability (Trees et al 2007). The management of ACL tears may be conservative, but most often requires reconstructive surgery (Trees et al 2007) of which the success rate ranges from 75% to 95% (Madhavan 2007). Despite treatment and technique advances, many patients still develop unsatisfactory post-operative outcomes, therefore warranting post-ACL reconstruction rehabilitation to assist the athlete in his return to pre-injury status (Trees et al 2007; Madhavan 2007, unpublished thesis). Rehabilitation programs are an important component of ACL post-surgical reconstruction, as successful return to full knee function may limit future degenerative changes to the knee joint (Trees et al 2007). The goals of post-operative ACL rehabilitation include controlling pain and swelling, restoration of knee range of motion (ROM), development of sufficient muscle strength for normal gait and restoring a good level of independence in performing the activities of daily living (ADL) (McDonald et al 2007). Rehabilitation may consist of exercise therapy (i.e. land- and water based exercises, supervised and home-based exercise, open- and closed kinetic chain exercises, weight-bearing exercises and neuromuscular and isokinetic strength training exercises, and other exercise) and cryotherapy (McDonald et al 2007;Trees et al 2007). These rehabilitation strategies typically commence during the acute in-patient period following ACL reconstruction surgery (McDonald et al 2007) and may later include prevention strategies for future ACL injuries. To date, no clinical 7.

(18) guideline exists reporting the superiority of one intervention over another (McDonald et al 2007, Trees et al 2007). An evidence-based clinical guideline explaining the management following ACL reconstruction surgery is therefore warranted. The purpose of this review was to systematically review the efficacy of various exercise therapies (i.e. land- and water based exercises, supervised and home-based exercise, open- and closed kinetic chain exercises, weight-bearing exercises, early quadriceps exercises and neuromuscular and isokinetic strength training exercises, and other exercises) and cryotherapy in decreasing pain and swelling, as well as improving knee function, knee ROM, and muscle strength in adults during the early and late phases of rehabilitation following ACL reconstruction surgery. The information obtained from this review was derived from systematic reviews (secondary research) to determine which rehabilitation strategies are most effective in improving outcome measurements (namely decreasing pain and swelling, as well as improving knee function, knee ROM, and muscle strength ROM, reduce swelling, improving muscle strength and functional activity) following ACL reconstruction surgery. The outcome of this review could possibly initiate a management guideline for post-ACL reconstruction in early and late phases of rehabilitation. 2.2 PROJECT AIM The primary aim of this review was to systematically assess the literature and present the best evidence available for the efficacy of various exercise therapies (i.e. land- and water based exercises, supervised and home-based exercise, open- and closed kinetic chain exercises, weight-bearing exercises, early quadriceps exercises and neuromuscular and isokinetic strength training exercises, and other exercises) and cryotherapy in decreasing pain and swelling, as well as improving knee function, knee ROM, and muscle strength in adults during the early and late phases of rehabilitation following ACL reconstruction surgery. This review also aimed at developing clinical recommendations for each of the included interventions. 2.3 RESEARCH QUESTIONS 1. What is the efficacy of various exercise therapies (i.e. land- and water based exercises, supervised and home-based exercise, open- and closed kinetic chain exercises, weight-bearing exercises, early quadriceps exercises, and neuromuscular and isokinetic strength training exercises, and other exercises) and 8.

(19) cryotherapy in decreasing pain and swelling, as well as improving knee function, knee ROM, and muscle strength in adults during the early and late phases of rehabilitation following ACL reconstruction surgery? 2. Which clinical recommendations can be made from the reviewed interventions (i.e. land- and water based exercises, supervised and home-based exercise, open- and closed kinetic chain exercises, weight-bearing exercises, early quadriceps exercises and neuromuscular and isokinetic strength training exercises, and other exercises and cryotherapy)? 2.4 OBJECTIVES The specific objectives of this review were to: •. Determine the efficacy of land - and water-based exercises on improving knee ROM, knee function, reducing swelling, and increasing muscle strength during the early and late phases of rehabilitation following ACL reconstruction surgery in adults.. •. Determine the efficacy of supervised and home-based exercises on improving knee ROM, knee function, reducing swelling, and increasing muscle strength during the early and late phases of rehabilitation following ACL reconstruction surgery in adults.. •. Determine the efficacy of open- and closed- kinematic chain exercises on improving knee ROM, knee function, reducing swelling, and increasing muscle strength during the early and late phases of rehabilitation following ACL reconstruction surgery in adults.. •. Determine the efficacy of immediate and late weight-bearing exercises on improving knee ROM, knee function, reducing swelling, and increasing muscle strength during the early and late phases of rehabilitation following ACL reconstruction surgery in adults.. •. Determine the efficacy of neuromuscular and isokinetic muscle strength training on improving knee ROM, knee function, reducing swelling, and increasing muscle strength during the early and late phases of rehabilitation following ACL reconstruction surgery in adults.. •. Determine the efficacy of early quadriceps exercises muscle strength training on improving knee ROM, knee function, reducing swelling, and increasing muscle strength during the early and late phases of rehabilitation following ACL reconstruction surgery in adults. 9.

(20) •. Determine the efficacy of specific exercises (such as lateral slide exercises, cycling, isokinetic muscle training, stair climbing and standard training) on improving knee ROM, knee function, reducing swelling, and increasing muscle strength during the early and late phases of rehabilitation following ACL reconstruction surgery in adults.. •. Determine the efficacy of cryotherapy on improving knee ROM, knee function, reducing swelling, and increasing muscle strength during the early and late phases of rehabilitation following ACL reconstruction surgery in adults.. •. Determine the efficacy of rehabilitation strategies namely neuromuscular training (plyometric power, biomechanics and techniques, strength, balance and core stability training) for decreasing the biomechanical risk factors for ACL injury, thereby preventing future injuries following ACL reconstruction surgery.. •. Develop specific clinical recommendations for each of the reviewed interventions with a view to include them in an evidence-based educational program for adults who will undergo ACL reconstruction surgery.. 2.5 DEFINITIONS ACL reconstruction: The anterior cruciate ligament (ACL) is one of a pair of ligaments in the center of the knee joint that form a ‘cross’, and this is where the name "cruciate" comes from. There is both an anterior and a posterior cruciate ligament (PCL). Both of these ligaments function to stabilize the knee from anterior to posterior. In medical terms, the ACL is the primary restraint to anterior displacement of the tibia on the femur. This means that when the ACL is injured, the tibia can slide forward on the femur, causing the knee to "give way" (Triston et al 2005). Adult: one who has reached maturity, an individual aged 18 years and older (http://dict.die.net/adult/) 2.6 METHODS OF REVIEW 2.6.1 Criteria for considering studies 2.6.1.1 Types of studies All published systematic reviews that investigated the effectiveness or efficacy of exercise therapies (i.e. land- and water based exercises, supervised and home-based exercise, open- and closed kinetic chain exercises, weight-bearing exercises and neuromuscular and isokinetic strength training exercises, quadriceps exercises and other exercises) and 10.

(21) cryotherapy in decreasing pain and swelling, as well as improving knee function, knee ROM, and muscle strength in adults during the early and late phases of rehabilitation following ACL reconstruction surgery were selected for this review. In addition, systematic reviews reporting on prevention strategies for preventing future ACL injuries following ACL reconstruction rehabilitation were sought. Other research designs, such as, observational studies and case studies, were excluded. Only systematic reviews published in the English and Arabic languages were sought for this review. Systematic reviews published after 2000 were included. 2.6.1.2 Type of Participants Systematic reviews that included male and female adults over eighteen years of age who had undergone ACL reconstruction surgery were included in the review. 2.6.1.3 Type of Interventions Systematic reviews that included exercise therapies (i.e. land- and water based exercises, supervised and home-based exercise, open- and closed kinetic chain exercises, weightbearing exercises and neuromuscular and isokinetic strength training exercises, quadriceps exercises, and other exercises) and cryotherapy in decreasing pain and swelling, as well as improving knee function, knee ROM, and muscle strength in adults during the early and late phases of rehabilitation following ACL reconstruction surgery were considered eligible. Interventions had to be administered by a physiotherapist or physical therapist. Systematic reviews reporting on prevention strategies for preventing future ACL injuries following ACL reconstruction rehabilitation were also sought. 2.6.1.4. Type of Comparisons Systematic reviews that compared land- to water based exercises, supervised to homebased exercise, open-to closed kinetic chain exercises, immediate and late weight-bearing exercises and neuromuscular to isokinetic strength training exercises, early quadriceps exercises to not allowing early quadriceps exercises, and other exercises) were sought. In addition, systematic reviews comparing cryotherapy to no intervention or another physiotherapeutic intervention were also included. 2.6.1.5 Types of Outcome measures Studies that incorporated the following outcomes were included: 1. Pain as measured with a Visual analog scale (VAS). 11.

(22) 2. Knee range of motion as measured with a goniometer. 3. Knee swelling measured with a tape measure. 4. Muscle strength of quadriceps and hamstring muscles as measured with isokinetic equipments. 5. Knee function as measured with a disability outcome measurement tool i.e. activity VMO, Tegner Activity Scale, Cincinnati Knee Rating system, KT1000, and standard pre-participation physical examination and Knee injury and Osteoarthritis Outcome Score (KOOS). 2.6.2 Search strategy for identification of studies Prior to commencing this review, PubMed/Medline, PEDro, Cochrane library and CINAHL were searched to determine if a similar review has ever been published. No similar reviews were found prior August 2007. An extensive search of the databases was conducted using the following keywords and combinations. This search strategy was designed for PubMed/Medline and CINAHL, and was adapted for each database. The databases included: PEDro, Cochrane Library, Sports Discus, Web of Science, Science Direct, Google Scholar, EbscoHost, ProQuest, PsycInfo, BMJ.com, Scirus, and NLM Central Gateway. These databases can be accessed via the library Website of Stellenbosch University. The searches were updated during March 2009 prior to publication. PubMED and CINAHL were searched using their MeSH functions. The MeSH function condenses the keywords to build the most appropriate search strategies. PubMED and CINAHL functions allow terms to be combined using Boolean terms such as ‘AND’ and ‘OR’ .This benefits the outcome of the search strategy by being more precise while saving time. As each database has its own indexing terms and search functions, and search strategies were adapted to suit each database individually. The following keywords were used as combinations during each search: Anterior cruciate ligament, anterior cruciate ligament reconstruction, physiotherapy, and physical therapy, exercise, exercises, therapy exercises, hydrotherapy, water therapy, cryotherapy, cold and cool therapies. The following is a basic search strategy using the indicated search terms and was adapted for each database (the individual search strategies for each database can be found in the appendix (addendum A) 1. 2. 3. 4. 5. 6.. anterior cruciate ligament (MeSH) #1 AND reconstruction #2 AND physiotherapy #2 AND physical therapy #2 and physi* #2 AND exercise. 12.

(23) 7. 8. 9. 10. 11. 12. 13. 14. 15.. #2 AND exercises #2 AND exercise therapy #2 AND hydrotherapy #2 AND water therapy #2 AND cryotherapy #2 AND cold therapy #2 AND cool therapy #1 AND injury prevention #1 AND prevention AND injuries. The following limits were applied in the databases: Systematic reviews that were reported in English and Arabic, Humans; female and male adult 18+ years. Dates of publications of systematic reviews were limited from the year 2000 to present. Secondary methods of searching included: •. Pearling The references lists of all publications of included and excluded systematic reviews were searched for additional systematic reviews.. •. Content experts Content experts were not contacted due to time constraints.. 2.6.3 Level of evidence allocation The hierarchical system of evidence as described by JBI was used to determine the level of evidence of the eligible systematic reviews (Table 2.1). The level of evidence is a reflection of the degree to which bias has been considered within the study design. The studies sought in this review were all systematic reviews of randomized control trials, and should therefore denote Level 1 evidence in this hierarchy of evidence. The JBI hierarchy is illustrated in Table 2.1. Table 2.1 JBI scale for level of evidence Level 1 Level 2 Level 3.1 Level 3.2 Level 3.3 Level 4. Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs). Evidence obtained from at least one properly designed RCT. Evidence obtained from well-designed controlled trials without randomization. Evidence obtained from well-designed cohort case control analytical studies. Evidence obtained from multiple time series with/without an intervention Dramatic results in uncontrolled experiments. Opinion of respected authorities based on clinical experience, descriptive studies or reports of expert committees.. 2.6.4 Assessment of methodological quality Two reviewers independently critically appraised the included systematic reviews. A third reviewer was consulted if there was any disagreement between the reviewers. The critical appraisal tool of Greenhalgh (1997) appraises the methodology of systematic reviews (Addendum A). The Greenhalgh critical appraisal tool consists of five questions, each requiring a yes/no response, with a ‘yes’ response being allocated one point, and a 13.

(24) ‘no/unclear’ allocated zero point. Studies scoring 3 out of 5 and above, on the Greenhalgh critical appraisal tool were included in the review. 2.6.5 Data storage For tracking purposes, all systematic reviews obtained for this review were recorded on a data storage form. This provided details about the article’s authors, title and source, which database the article was retrieved from and the location where the article is being stored. 2.6.6 Data extraction Data from included studies was placed into data extraction sheets to systematically catalogue the following information: year, country, author, title, objective, inclusion criteria (study), inclusion criteria (sample), inclusion criteria (language and search year), databases, methodological appraisal (which tool), method of review, outcome measurement, intervention (type of treatment), intervention ( Dosage, frequency, and treatment period), control (type of treatment), control ( Dosage, frequency, and treatment period), number of studies, data analysis, presentation of statistics, meta-analysis, main finding, clinical application, heterogeneity of discussion. 2.6.7 Data synthesis The heterogeneous nature of the systematic reviews prevented the results to being pooled in meta-analysis. Consequently the results were presented in a narrative summary. 2.7 RESULTS 2.7.1 Search results The search for published secondary research into the efficacy of exercise therapies (i.e. land- and water based exercises, supervised and home-based exercise, open- and closed kinetic chain exercises, weight-bearing exercises and neuromuscular and isokinetic strength training exercises, early quadriceps exercises to not allowing early quadriceps exercises and other exercises) and cryotherapy in decreasing pain and swelling, as well as improving knee function, knee ROM, and muscle strength in adults during the early and late phases of rehabilitation following ACL reconstruction surgery, including preventative strategies, yielded 388 hits. Of this total, 275 hits were excluded after reviewing the title, as they clearly did not conform to the inclusion criteria. The abstracts of the remaining 113 were retrieved, and 85 articles were further excluded as they did not meet the inclusion criteria. This left the reviewer with 31 potentially eligible studies, of which the full-text was 14.

(25) retrieved. Ten of these were duplications, and were excluded. A further 12 were excluded after reviewing the full-text, as they did not completely meet the inclusion criteria. Consequently, eight systematic reviews were included in this review (Trees et al 2007, Risberg et al 2004, Raynor et al 2005, Permall et al 2008, Wright et al 2008 (a and b), Owen et al 2006 and Hewett et al 2005). Figure 2.1 depicts the results of the search.. 15.

(26) •. PEDro (n=10). •. Cinahl (n =16). •. NLM Central Gateway (n=0). •. Cochrane Library (n=4). •. BMJ.com (n=27). •. PEDro (n = 110). •. Proquest (n=9). •. Psycinfo (n =28) •. Pubmed (n =52). •. ScienceDirect (n =10). •. Sports Discus (n=17). •. Google Scholar (n=131). •. EBSCOhost (20). •. Web of Science (n=37). 388 Titles was screened by 1 independent reviewer Excluded Articles (n =275) as title did not conform to review objectives. 113 abstracts were retrieved and read by the principle reviewer.. Excluded Articles (n = 82) as study design and methodology did not conform to review objectives.. 31 Articles selected on abstract, full text retrieved and read by principle reviewer.. Excluded (n = 23) further investigation revealed that articles did not conform to review objectives.. Total number of articles included in this review: 8. Figure 2.1: Database search results. 16.

(27) 2.7.2 Level of evidence The evidence levels of the systematic reviews were allocated using the JBI scale of level of evidence (Table 2.2). The majority of the included systematic reviews denoted Level 1 evidence on the JBI scale of evidence as they included RCTs. Only one systematic review however included six studies: four of which denoted level I evidence and the other three denoted level 3.2 evidence. The results of the allocation of evidence levels of the eight systematic reviews are illustrated in (Table 2.2). In addition, to develop clinical recommendation for the included interventions, the NHMRC guidelines for developing clinical guidelines will be used. Table 2.2 Level of evidence results using JBI level of evidence scale. No.. Author. 1. 2. 3.. Risberg et al 2004 Raynor et al 2005 Hewett et al 2005. Nr of studies / RCTs 33 7 6. 4.. Owen et al 2006. 4. 5. 6. 7. 8.. Trees et al 2007 Wright et al 2008a Wright et al 2008b Permall et al 2008. 9 54 54 3. Type of studies. Level of evidence. RCTs RCTs 3 RCTs and 3 prospective cohort studies Prospective randomized intervention study, prospective controlled study, and systematic review. RCTs RCTs and clinical trials RCTs and clinical trials RCTs. Level 1 Level 1 Level 1 Level 3.2 Level 1 Level 1 Level 1 Level 1 Level 1. 2.7.3 Methodological appraisal Five of the eight included systematic reviews scored 5/5 on Greenhalgh’s critical appraisal tool (Risberg et al 2004, Trees et al 2007, Permall et al 2008 and Wright et al 2008 (a and b)). One systematic review scored 4/5 (Raynor et al 2005). The remaining 2 systematic reviews scored 3/5 on the critical appraisal tool (Owen et al 2006 and Hewett et al 2005). Two studies did not perform a thorough search (Owen et al 2006 and Hewett et al 2005) and three studies did not appraise the methodological quality of the trials that they had included (Raynor et al 2005, Owen et al 2006 and Hewett et al 2005.). The results of the scoring of the eight systematic reviews are illustrated in table 2.3.. 17.

(28) Table 2.3: Methodological quality result of included systematic reviews using Greenhalgh critical appraisal tool: Criteria. Risberg et al 2004. Hewett et al 2005. Raynor et al 2005. Owen et al 2006. Trees et al 2007. Wright et al 2008a. Wright et al 2008b. Permall et al 2008. 1. Can you find an important clinical question which the review addressed? 2. Was a thorough search done of the appropriate databases and were other potentially important sources explored? 3. Was methodological quality assessed and the trials weighted? 4. How sensitive are the results to the review which has been done? 5. Have the numerical results been interpreted with common sense and due regard to the broader aspects of the problem? Total score. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. No. Yes. No. Yes. Yes. Yes. Yes. Yes. No. No. No. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. Yes. 5/5. 3/5. 4/5. 3/5. 5/5. 5/5. 5/5. 5/5. 2.7.4 General description of reviews All of the included eight systematic reviews were fully reported from medical journals indexed in the electronic databases. All included reviews were published in the English language and their publication dates span across four years (2004-2008). The systematic reviews were conducted in six countries, UK (one review), USA (three reviews*), Canada (one review), Switzerland (one review), South Africa (one review) and Norway/ USA (one review*) (Table 2.4) Six systematic reviews evaluated rehabilitation following ACL reconstruction (Trees et al 2007, Risberg et al 2004, Raynor et al 2005, Permall et al 2008 and Wright et al 2008 (a and b)). Two systematic reviews evaluated the possibility of ACL injury prevention among athletes following ACL reconstruction (Hewett et al 2005 and Owen et al 2006). The total sample size for the eight included systematic reviews was n=14709. All populations were adult and varied between the ages of 18 to 48 years. The majority of the included systematic reviews included male and female participants except one systematic review which included only female participants (Hewett et al 2005). Patient populations, age range, gender, type and number of studies were described in all systematic reviews (Table 4). The recall periods referring to follow-up periods of ACL reconstruction postoperative 18.

(29) rehabilitation varied from 0-24 month’s life-time follow up. The recall periods for ACL injuries prevention training programs varied from 4 weeks to 2 years life-time follow up. All eight systematic reviews provided a definition for ACL reconstruction and for the rehabilitation training technique used. The definitions reported in the systematic reviews are listed in Table 2.4 below.. 19.

(30) Table 2.4: General description of included studies Author. Year. Country. Intervention. Definition. Age. Gender. Risberg et al. 2004. USA /Norway. Exercise therapy, Hydrotherapy. 14-48. Raynor et al. 2005. Switzerland. Cryotherapy. Hewett et al. 2005. USA. Prevention injuries by neuromuscular training. Owen et al. 2006. Canada. Prevention of ACL injury without previous ACL pathology by proprioception balance training.. Neuromuscular training, weight bearing , Strength, OKC, CKC exercises and exercises in water Common treatment modality after surgery procedures and several cryotherapy devices (ice packs, gel packs, braces with circulating ice water) are commonly used. polymeric power, biomechanics and technique, strength, balance and core stability training proprioception balance training. Trees et al. 2007. UK. Exercise therapy, hydrotherapy. Wright et al a Wright et al b. 2008. USA. Exercise therapy,. 2008. USA. Permall et al. 2008. SA. Exercise therapy, acceleration rehabilitation and miscellaneous topics the effect and safety of early postoperative quadriceps exercise. Strength, OKC,CKC , weight bearing exercises, and exercises in water Early weight bearing and homebased rehabilitation OKC versus CKC exercises, accelerated rehabilitation and miscellaneous topics early postoperative quadriceps exercise via a rehabilitation program not allowing early quadriceps exercises or restricting quadriceps exercise training to only isometric quadriceps contractions in postoperative adult ACL reconstruction patients. 20. M-F. Sample size 1244. Type of studies RCTs. Nr of studies 33. 25-34. M-F. 172. RCTs. 7. 14-20. F. 9909. 6. 16-20. M-F. 932. 15-48. M-F. 391. RCTs or prospective cohort study Prospective randomized intervention study, prospective controlled study, and systematic review. RCTs. Age>15. M-F. 819. RCTs. 54. Age>15. M-F. 1057. RCTs. 54. M-F. 185. RCTs. 3. 4. 9.

(31) 2.7.5 Outcomes measured in included systematic reviews All of the authors used different outcome measures and scales to measure the effectiveness of their interventions. Outcome measurement and scales encountered after ACL reconstruction in adults are listed in table 2.5 below. The most commonly measured outcomes were range of motion (Risberg et al 2004, Raynor et al 2005, Trees et al 2007, Permall et al 2008, and Wright et al 2008a and b) and muscle strength (Risberg et al 2004, Trees et al 2007, Owen et al 2006 and Wright et al 2008a and b). Pain was reported in five systematic reviews (Raynor et al 2005, Trees et al 2007, Permall et al 2008 and Wright et al 2008 (a and b)). All systematic reviews in this review used different outcome measures and different instruments measuring the outcomes, resulting in difficulty when attempting to combine the results from the systematic reviews. The measurement of the outcomes for the systematic reviews varied between immediate postoperative and a 2- year follow-up. Table 2.5: Outcomes measured in included systematic reviews Outcomes. Outcome measurement tool. Risberg et al 2004. Raynor et al 2005. ROM Muscle strength. Goniometer EMG. X X. X. Lysholm score EMG activity VMO Leg girth reflex hamstring contraction latency (RHCL) KT1000 hemoVac output. X X X X. Reflex Knee laxity Postoperative drainage Pain Activity. Muscle activation. Static measures of joint stability. Visual Analogue Scale (V.A.S). Tegner Activity scale Cincinnati knee Rating system Functional hop tests Average isokinetic torque EMG. X. Hewett et al 2005. Owen et al 2006. Trees et al 2007. Wright et al 2008a. Wright et al 2008b. Permall et al 2008. X. X X. X X. X X. X X. X X. X X X. X. X. X. X. X. X. X. X. X. X. X. X. X. X. X. X X. X X X. X X. Flexibility Plyometrics sport specific agility drills speed enhancement athlete education Standard preparticipation physical examinations. X X X X X. 21. X. X. X. X.

(32) 2.7.6 Interventions All patients received a postoperative rehabilitation program immediately after surgery (Trees et al 2007, Risberg et al 2004, Permall et al 2008, Wright et al 2008 (a and b) and Raynor et al 2005). There were several postoperative interventions utilized and the following sections will provide a summary of the postoperative management utilized by each systematic review. Intervention 6 systematic reviews. Exercises 5 systematic reviews. Cryotherapy 1 systematic review. Figure 2.2 Summary of post-ACL reconstruction rehabilitation interventions. 2.7.6.1 Exercise Therapies following ACL reconstruction surgery The following section will describe the various exercise therapies reported in the included systematic reviews. In addition, appropriate clinical recommendations for each intervention were developed using the NHMRC guidelines for clinical guidelines, namely the level, quality, relevance and strength of each intervention was determined. 2.7.6.1.1 Land-based versus water-based rehabilitation Three of the eight included systematic reviews (Risberg et al 2004, Trees et al 2007, and Wright et al 2008b) reported on one study (Tovin et al 1994) which compared the effect of land-based exercises on improving muscle strength (Risberg et al 2004, Trees et al 2007, and Wright et al 2008b), decreasing joint effusion (Risberg et al 2004, Wright et al 2008b) and increasing knee ROM (Wright et al 2008b) to water-based exercises (See table 2.6). • Level of evidence: Tovin et al (1994) was the only study reviewed in all of the three systematic review, therefore denoting level 2 evidence for land-based and water-based exercises in the rehabilitation following ACL reconstruction surgery. • Quality of evidence: The three systematic reviews which reported on the effect of land-and water-based exercises following ACL reconstruction each scored 5 out of 5 on the Greenhalgh critical appraisal tool, indicating high methodological quality. • Relevance of evidence: Clinical outcomes, namely knee ROM, muscle strength, joint effusion were measured by Tovin et al (1994), which indicates that the 22.

(33) information retrieved from the trial was clinically relevant to patients post ACL reconstruction surgery. • Strength of evidence: The results from the three reviews stated that water-based exercises were significantly better at decreasing joint effusion (Risberg et al 2004) and improving muscle strength; in Trees et al 2007 it was reported as a weighted mean difference of 9.80 95% CI 1.29 to 18.31 on the Lysholm scale; in Wright et a 2008b it was reported that the water-based exercise group did significantly better with a p=0.03. In Risberg et al (2004), no numerical data was given for outcome measurements. Trees et al (2007) reported a wide 95% CI range which indicates weak evidence. Table 2.6: Land-based versus water-based exercises Author. Intervention group (1). Intervention Dosage. Control group (2). Control Dosage. Outcome measure. Finding /stats. Tovin et al 1994. water based rehabilitation including exercises in water and home exercises water based rehabilitation. 8 Wks. land based rehabilitation including exercises and home exercises. 8 Wks. Lysolm score. WMD 9.80: 95% CI: 1.29 to 18.31 Higher Lysolm score in group 1. 8 Wks. land based rehabilitation. 8 Wks. Peak isokinetic muscle toque (8 weeks). WMD-14.70: 95% CI:-25.89 to -3.51 (this seems to be ineffective). Tovin et al 1994. Key: wks = weeks. Clinical recommendation The evidence available for the effect of water- and land-based exercises in the rehabilitation of ACL reconstruction is inconclusive. Therefore, no recommendation as to which exercise should rather be used, or as to which exercise is better than the other can be made. At this point, both exercises are equally suitable to be used during post-ACL reconstruction rehabilitation. 2.7.6.1.2 Supervised and home-based rehabilitation programs. Three systematic reviews (Trees et al 2007; Risberg et al 2004 and Wright et al 2008a) described the effect of supervised rehabilitation programs on increasing knee ROM, muscle strength, and decreasing laxity compared to home-based rehabilitation programs. The supervised programs were directly monitored by physiotherapists, whereas the homebased programs were not. Patients in the home-based program group had to report back to the physiotherapist. Trees et al (2007) reported on two studies (Beard 1998; Fischer 1998) comparing the effect of supervised and home-based rehabilitation programs on 23.

(34) increasing knee ROM. Trees et al (2007) and Wright et al (2008b) reported the effect of supervised and home-based rehabilitation programs on increasing knee ROM (Fischer 1998; Grant et al 2005). The effect of supervised and home-based rehabilitation programs on improving muscle strength, and decreasing knee laxity was reported in Risberg et al (2004),Trees et al (2007) and Wright et al (2008a). (See table 2.7) • Level of evidence: In total, four RCTs were included in the three systematic reviews which reported on the effect of supervised programs compared to homebased programs in increasing knee ROM, muscle strength, and decreasing laxity. There is level 1 evidence for the effect of supervised and home-based rehabilitation programs following ACL reconstruction surgery. • Quality of evidence: The three systematic reviews which reported on the effect of supervised rehabilitation program compared to home-based programs following ACL reconstruction each scored 5 out of 5 on the Greenhalgh critical appraisal tool, indicating high methodological quality. • Relevance of evidence: Clinical outcomes, namely knee ROM, muscle strength, and decreasing knee laxity were reported by the three systematic reviews (Trees et al 2007; Risberg et al 2004 and Wright et al 2008a) which indicate that the information retrieved from the trials was clinically relevant to patients post ACL reconstruction surgery. • Strength of evidence: Fischer (1998) found that there was significant difference (in favour of the home-based rehabilitation program group) between the groups in the ROM, the weighted mean difference on 18 weeks was -6.00 (95% CI -11.76 to 0.24) and after 24 weeks was -8.00 (95% CI -12.92 to -3.08) in increasing knee ROM. Fischer (1998) reported that home-based rehabilitation programs were understandable, convenient, and reliable and could be used for many patients undergoing ACL reconstruction (Trees et al 2007 and Wright et al 2008b). Beard (1998), however, found that there was no significant difference between the groups in improving muscle strength. The weighted mean difference on 6 months was 9.00 (95% CI -2.41 to 20.41) (Risberg et al 2004, Trees et al 2007 and Wright et al 2008a). Beard (1998) also found that there was no significant difference between the groups in the Lysholm scores. The weighted mean difference on 6 months was 2.00 (95% CI -4.53 to 8.53). Tegner scores were used to evaluate the level of activity at 6 months after surgery. There was no significant difference found between the groups. The weighted mean difference was 6.00 (95% CI -6.71 to 24.

(35) 18.71). Beard (1998) found that there was no significant difference between the groups in knee laxity. The weighted mean difference on 6 months was - 2.50 (95% CI -5.41 to 0.4) (Risberg et al 2004, Trees et al 2007 and Wright et al 2008a). Two systematic reviews (Risberg et al 2004 and Wright et al 2008a) found that there was a significant difference between the groups in the number of visits required (P<.05) and weighted mean difference of 11.35 (95%CI 14.2 to 2.85) (Schenck et al 1997). Wright et al (2008a) reported that Grant et al (2005) found a significant difference in knee flexion and extension ROM. The home-based group had an acceptable rate of 96.8% for extension versus 83.3% for the physical therapy-based group (P=.02). The home-based group had an acceptable flexion rate of 66.7% versus 47% for the physical therapy therapy-based group (P=.03). No significant differences in knee laxity and strength between the two groups were found. Clinical recommendation From the evidence available, it can be recommended that home-based rehabilitation may be more effective at increasing knee ROM than supervised rehabilitation programs. No significant difference was reported between the supervised and home-based rehabilitation programs in improving muscle strength, decreasing knee laxity and Tegner scores.. 25.

(36) Table 2.7: Supervised versus home-based exercises Author. Intervention group (1). Intervention Dosage. Control group (2). Control Dosage. Outcome measure. Findings/ statistics. Schenck 1997. Home-based (6 PT visits). 0-6 visits. Clinical-based (24 PT visits). 6-40 visits. Lysholm (12 and 24 weeks). no significant finding. Schenck 1997. Home-based (6 PT visits). 0-6 visits. Clinical-based (24 PT visits). 6-40 visits. Knee ROM (18 weeks). (P<.05) and weighted mean difference of 11.35 95%CI 14.2 to 2.85.. Schenck 1997. Home-based (6 PT visits). 0-6 visits. Clinical-based (24 PT visits). 6-40 visits. Pain visual analogue scale, 1leg hope, instrument laxity, sickness profile. no significant finding. Fischer et al 1998. Home-based (6 PT visits). 6 visits/ 6month. Clinical-based (24 PT visits). 24 visits/6 month. Lysholm (12 and 24 weeks). WMD1.46, 95% CI -3.19 to 6.10. Beard and Dodd 1998. Supervised (knee class twice a week)+ home-based program. 12 wks. Home-based program. 12 wks. Knee ROM (18 weeks). WMD -6.00, 95% CI -11.76 to -0.24. Beard and Dodd 1998. Supervised (knee class twice a week) +home-based program. 12 wks. Home-based program. 12 wks. VAS. WMD - 8.00, 95% CI -12.92 to -3.08. Grant et al 2005. Minimally supervised homebased. 4 sessions 612 wks. Traditional Supervised protocol (PT). 17 sessions 612wks. instrument laxity and strength. no significant finding. Grant et al 2005. Minimally supervised homebased. 4 sessions 612 wks. Traditional Supervised protocol (PT). 17 sessions 6 12 wks. ROM. Group 1 extension (P=.02) Flexion (P=.03). 26.

(37) 2.7.6.1.3 Open kinetic chain (OKC) or closed kinetic chain (CKC) exercises Three systematic reviews (Trees et al 2007, Risberg et al 2004 and Wright et al 2008b) reported on the effectiveness of CKC and OKC exercises on improving knee function, increasing knee ROM, decreasing patellofemoral pain and decreasing knee laxity following ACL reconstruction rehabilitation (Beynnon et al 1998, Bynum et al 1995, Hooper et al 2001, Mikkelsen et al 2000, Morrissey et al 2000, and Morrissey et al 2002). (See table 2.8) • Level of evidence: In total, six RCT were included in the three systematic reviews. Therefore the level of evidence for the effect of CKC and OKC exercises denotes level 1 evidence following ACL reconstruction surgery. • Quality of evidence: The three systematic reviews which reported on the effect of CKC and OKC exercises following ACL reconstruction each scored 5 out of 5 on the Greenhalgh critical appraisal tool, indicating high methodological quality, or quality of evidence. • Relevance of evidence: Clinical outcomes, namely knee function, ROM, patellofemoral pain and knee laxity were reported by the three systematic reviews (Trees et al 2007; Risberg et al 2004 and Wright et al 2008a) which indicates that the information retrieved from the trials was clinically relevant to patients post ACL reconstruction surgery. • Strength of evidence: Bynum et al (1995) found that there was significant difference noted in KT-1000 maximum values at 24 weeks with the CKC group reporting 1.6 mm and the OKC group reporting 3.3 mm (p=.02) (Wright et al 2008b). Patellofemoral pain was severe enough to restrict activity at one year. In Trees et al (2007) a Relative Risk 1.34,95% CI .59 to 3.07 was reported and in Wright et al (2008b) it was reported that at 9 months evaluation, patellofemoral pain was noted in 15% of the CKC group versus 38% in the OKC group (p=.046). Subjective patient assessments, Lysholm and Tegner scores were equivalent in both groups. 21 of the 50 subjects in CKC group felt that they had returned to normal activities of daily living sooner than expected versus 10 of the 46 subjects in the OKC group (p=.007) (Wright et al 2008b). Negative Lachman test measurements at one year was reported as a Relative Risk of 0.93, 95% CI 0.80 to 1.09 (Trees et al 2007). *Hooper et al (2001) found that there was no significant difference between the groups in knee function (Houghston knee functional score). The weighted mean difference at 6 weeks was 0.00 (95% CI -9.34 to 9.34) (Trees et al 2007 and Wright 27.

(38) et al 2008b). *Mikkelsen et al (2000) found that there were significant differences in CKC and OKC rehabilitation program compared to the CKC only programs on return to pre-injury level of sport by 31 months after ACL reconstruction surgery, reported as a Relative Risk 0.42,95% CI .18 to .98 (Trees et al 2007) and with p< 0.05 in Wright et al (2008b). Morrissey et al 2000 assessed knee laxity using the Knee Signature System at 2 and 6 weeks. The OKC group was determined to be 9% more lax, with the 95% confidence interval ranging from -8% to +29% (Wright et al 2008b). Morrissey et al (2002) evaluated pain, isokinetic and isometric testing performed at 2 and 6 weeks, and 3 questions from Houghston clinical score were assessed. The result with was that there no difference in the pain scores. Beynnon et al (1998) found that in order to minimize the strain on ACL during quadriceps muscle strength training, the knee should be maintained in less than 60 degrees during CKC exercises with knee angles greater than 40 of flexion. Clinical recommendation From the available evidence, it can be recommended that a combination of OKC and CKC exercises should be incorporated into the rehabilitation program following ACL reconstruction surgery.. 28.

(39) Table 2.8: Open kinetic chain (OKC) versus closed kinetic chain (CKC) exercises Author. group (1). Group (1) Dosage 4 wks. Group (2). Group(2) Dosage. Outcome measure. Finding/ stats. Hooper 2001. CKC rehabilitation. OKC rehabilitation. 4wks. WMD 0.00, 95% CI 9.34 to 9.34. CKC rehabilitation. 24 wks. OKC rehabilitation. 24 wks. Bynum 1995. CKC rehabilitation. 24 wks. OKC rehabilitation. 24 wks. Mikkelsen 2000. CKC rehabilitation. 24 wks. OKC and CKC rehabilitation. 24 wks. Mikkelsen et al 2000. CKC rehabilitation. 12wks. OKC rehabilitation. 6wks. Houghston Clinic Functional score at 6 weeks post surgery Patellofemoral pain sever at one year Negative Lachman test at one year Return to preinjury level of sport by 31 months after surgery Instrument laxity (KT-1000) at 6 month. Bynum 1995. Mikkelsen 2000. CKC rehabilitation. 12 wks. OKC rehabilitation. 6 wks. Mikkelsen 2000. CKC rehabilitation. 12 wks. OKC rehabilitation. 6 wks. Morrissey 2000. CKC rehabilitation. 3-6 wks. OKC rehabilitation. 2-6 wks. Key:. Isokinetic strength testing) at 6 month Patient satisfaction at an average of 31 months. Instrument laxity (Knee Significant System) at 26wks. RR 1.34, 95% CI 0.59 to 3.07 RR 0.93, 95% CI 0.80 to 1.09 RR 0.42, 95% CI 0.18 to 0.98 no significant difference in knee laxity no statistics were cited (P<.05) higher rate of patients in OKC return to sports at the same level than in CKC group OKC group determined to 9% looser,95% CI-8% to +29%. 2.7.6.1.4 Immediate versus late weight bearing (WB) exercise. Two of the eight included systematic reviews (Risberg et al 2004, and Wright et al 2008b) reported on the effect of immediate versus late WB exercises on improving ROM, stability of knee, knee function, vastus medialis oblique strength and anterior knee pain (Risberg et al 2004 and Wright et al 2008b) (See table 2.9). • Level of evidence: In total, one RCT was included in the two systematic reviews which reported on the effect of immediate versus late WB exercises in improving ROM, stability of knee, knee function, vastus medialis oblique strength and anterior knee pain following ACL reconstruction surgery, denoting level 2 evidence. • Quality of evidence: The two systematic reviews which reported on the effect of immediate versus late WB exercises following ACL reconstruction each scored 5 29.

(40) out of 5 on the Greenhalgh critical appraisal tool, indicating high methodological quality, or quality of evidence. • Relevance of evidence: Clinical outcomes, namely ROM, stability of knee, knee function, vastus medialis oblique strength and anterior knee pain were reported by the two systematic reviews (Risberg et al 2004 and Wright et al 2008b) which indicate that the information retrieved from the trial was clinically relevant to patients post ACL reconstruction surgery. • Strength of evidence: The results from the two reviews stated that in Tyler et al (1998 ) the effect of immediate WB were significantly better at improving Vastus medialis oblique activity at 2 weeks with p=.02 (Risberg et al 2004 and Wright et al 2008b). Lysholm scores demonstrated a significantly greater improvement preoperatively in the immediate WB group (p=0.03) (Tyler et al 1998). Anterior knee pain was evaluated (Tyler et al 1998) using questions from the Lysholm scale reported pain to be significantly decreased in the immediate WB group (p=.03) (Risberg et al 2004, and Wright et al 2008b). No statistical different was noted at 2 weeks or 14 months for knee ROM (Risberg et al 2004, and Wright et al 2008b). Clinical Recommendation It is recommended that immediate WB exercises be incorporated into ACL reconstruction rehabilitation to improve muscle strength, knee function and decrease knee pain. Table 2.9: Immediate versus late weight bearing (WB) exercise. Author. Group(1). Tyler et al 1998. Immediate weight bear as tolerated. Group(1) Dosage 2 wks. Group (2) WB after 2 weeks of surgery. Group(2) Dosage 2wks. 30. Outcome measure EMG activity VMO. Finding/stats There was no effect of WB on ROM, VMO knee stability, EMG activity, Lysholm score and anterior knee pain.

(41) 2.7.6.1.5 Quadriceps exercise One systematic review described the effect and safety of early postoperative quadriceps exercises on increasing knee ROM, lower limb function, decreasing pain, and laxity compared to a rehabilitation program not allowing early quadriceps exercises or restricting quadriceps exercise training to only isometric quadriceps contractions in postoperative adult ACL reconstruction patients (Permall et al 2008). Permall et al (2008) reported on three studies (Shaw et al 2005, Isberg et al 2006, and Friemert et al 2006) See table 2.10). • Level of evidence: In total, three RCTs were included in the one systematic review which reported on the effect and safety of early postoperative quadriceps exercise on increasing knee ROM, lower limb function, decreasing pain, and laxity compared to a rehabilitation program not allowing early quadriceps exercises or restricting quadriceps exercise training to only isometric quadriceps contractions in postoperative adult ACL reconstruction patients, denoting level 2 evidence. • Quality of evidence: The systematic review which reported on the effect and safety of early postoperative quadriceps exercise following ACL reconstruction scored 5 out of 5 on the Greenhalgh critical appraisal tool, indicating high methodological quality. • Relevance of evidence: Clinical outcomes namely knee ROM, lower limb function, pain, and knee laxity were reported by the systematic review (Permall et al 2008) which indicates that the information retrieved from the trial was clinically relevant to patients post ACL reconstruction surgery. • Strength of evidence: Shaw et al (2005) found that there was significant difference between the groups only in active knee flexion which was 5.9 (95% CI 0.1 to11.7) and extension 2.7 (0.1 to 5.3), no significant difference found in passive knee extension 1.2 (-0.8 to 3.2) on one month postoperatively. ROM measured over 6month follow-up period (pre-operative, day 1, week 2, 1 month, 3 months and 6 month post-operatively) (Permall et al 2008). Friemert et al (2006) reported that on 7 days postoperatively the effect size for active knee flexion in the study was 0.15 (small effect). Isberg et al (2006) measured ROM from 6-months to 2 years follow up. There were no values given in Isberg et al (2006) in active knee flexion in the study, and they mentioned that there was no significant difference between the groups in active knee flexion extension when comparing the intact and reconstructed knee for each individual patient (Isberg et al 2006).. 31.

(42) Shaw et al (2005) evaluated function by means of hop tests (single-leg-hope and triple-leg-hope tests). No significant differences were reported between the reconstructed leg strength relative to the non-operative leg at 6 month. The weighted mean difference on single-leg-hop test was 2.1 (95% CI -2.8 to 7) and triple-leg-hop test was 1.9 (95% CI -3.5 to 7.3). Isberg et al 2006 fond that there was no significant difference found between the groups measured by single-leg-hop test at 6 month postoperatively and at 2 years follow up. The median range was 97 (86-100) in intervention group and 96 (85-100) in control group (Isberg et al 2006). Subjective assessment of function was used by Shaw et al (2005) which was Cincinnati Knee Rating System (CKRS). Measurement was taken at 1, 3 and 6 months postoperatively. No significant differences between the groups were found. The weighted mean difference between the groups at 6 months was 4.8 (95% CI 1.4 to 11) (Shaw et al 2005). Shaw et al (2005) found that there was no significant difference between the groups in decreasing pain measured by VAS at day 1 week 2, 1 month, 3 months and 6 month postoperatively follow up. The weighted mean difference on 6 months for pain at rest was 0.00 (95% CI -0.3 to 0.3) and -0.1(95%CI -0.9 to 0.7) for performing exercise (Shaw et al 2005). CKRS evaluation system was also used to evaluate pain in Shaw et al (2005) study. Significant difference on 6 month postoperatively was reported between the groups and the intervention group reported higher results for pain. The weighted mean difference was 4.8.00 (95% CI -1.4 to 11.00). Shaw et al (2005) found that there was no significant difference between the groups in knee laxity measured by KT-1000 at 3 and 6 month post-operatively (p=0.99). Isberg et al (2006) used the KT-1000 and radiostereometric analysis (RSA) to evaluate anterior posterior laxity preoperatively, 6 months postoperatively and 2 years follow up. There was no significant difference between the groups in knee laxity (Table 12) (Isberg et al 2006).. 32.

(43) Table 2.10: A-P laxity preoperatively, at 6 months and 24 months follow up (Isberg et al 2006) (Permall et al 2008).. Preoperative 6 months 24 month Pre-op v.24 months. RSA Intervention median (range) in mm 8.6 (2.3-15.4) 3.4(0.6-11.5) 2.7 (0-10.7) P=0.005. RSA Control median (range)in mm 7.2(2.2-17.4) 3.4(-3.3 to 7.8) 2.8 (-1.8 to 9.5) P=0.005. KT-1000 intervention median (range) in mm 2.0(0-8.0) 0 (-3.0 to 1.5) 1.0 (-1.5 to 3.5) P=0.0096. KT-1000 Control median (range)in mm 4.0(0-10.10) 1.5 (0.5 to 4.5) 0.5 (-1.0 to 4.0) P=0.004. A-P laxity: an anterior posterior side to side difference of greater than 3 mm or greater than 5 mm on testing with the KT-1000 arthrometer. Clinical recommendation From the evidence available, it can be recommended that early quadriceps exercises can be performed safely in the first 2 postoperatively weeks. But clinically, no significant difference was reported between the intervention and control groups using quadriceps exercises in improving ROM, functional performance, decreasing knee laxity and pain. 2.7.6.1.6 Neuromuscular versus strength training Two of the eight included systematic reviews (Risberg et al 2004, and Wright et al 2008b) reported on one study (Liu-Ambrose et al 2003) which assessed the effects of strength training programs and neuromuscular/proprioception training programs on improving the functional activity using the Lysholm and Tegner scores, average isokinetic torque, and functional hop tests to assess compliance and hamstring peak torque time (Risberg et al 2004 and Wright et al 2008b) (See table 2.11). • Level of evidence: Liu-Ambrose et al (2003) was the only study reviewed in the two systematic reviews, therefore denoting level 2 evidence for neuromuscular and strength training exercises in the rehabilitation for ACL reconstruction surgery. • Quality of evidence: The two systematic reviews which reported on the effect of neuromuscular and strength training programs following ACL reconstruction each scored 5 out of 5 on the Greenhalgh critical appraisal tool, indicating high methodological quality, or quality of evidence. • Relevance of evidence: Clinical outcomes, namely improving the functional activity, compliance and hamstring peak torque time were reported by Risberg et al (2004) and Wright et al (2008b) indicates that the information retrieved from the trial was clinically relevant to patients post ACL reconstruction surgery. 33.

(44) • Strength of evidence: The results from the two reviews stated that the Lysholm and Tegner scores increased significantly in both groups (Risberg et al 2004 and Wright et al 2008b). The neuromuscular group demonstrated a greater change in isokinetic torque compared to the strength group after 12 weeks of training (hamstring: p=.04, quadriceps p=.005). Both groups showed statistically significant increases in their functional hop tests, but there were no significant differences between groups. Peak torque time decreased in the neuromuscular group at 6 weeks and then returned to baseline at 12 weeks (Risberg et al 2004 and Wright et al 2008b). Clinical recommendation The evidence available for the effect of strength training programs and neuromuscular training programs in the rehabilitation of ACL reconstruction is limited and inconclusive. Although the neuromuscular group demonstrated a greater change in isokinetic torque compared with the strength group, it cannot be recommended that the one training program be used instead of the other. Both training programs can therefore be used in the rehabilitation phase following ACL reconstruction. Table 2.11: Neuromuscular versus strength training Author. Group (1). Group (1) Dosage 12 wks. Group (2). Group (3) Dosage. Outcome measure. Finding/stats. Liu-Ambrose et al 2003. Proprioceptive training. Isotonic strength training Isotonic strength training. 12wks. Peak torque time. 12wks. Hamstring Concentric and eccentric. Both training protocols influenced Peak TT. Liu-Ambrose et al 2003. Proprioceptive training. 12 wks. Liu-Ambrose et al 2003. Proprioceptive training. 12 wks. Isotonic strength training. 12wks. Hamstring and quadriceps torque. Liu-Ambrose et al 2003. Proprioceptive training. 12 wks. Isotonic strength training. 12wks. One leg hope. Liu-Ambrose et al 2003. Proprioceptive training. 12wks. Isotonic strength training. 12wks. Lysholm score. 34. Proprioceptive training Alone can induce isokinetic strength gains Proprioceptive training Alone can induce isokinetic strength gains Proprioceptive training Alone can induce isokinetic strength gains.

(45) 2.7.6.1.7 Other specific exercises Two systematic reviews (Risberg et al 2004 and Wright et al 2008b) reported 7 RCTs, which had addressed more discrete issues in single studies regarding ACL reconstruction rehabilitation (Blanpied et al 2000, Cupal and Brewer 2001, Decker et al 2004, Draper 1990, Shaw et al 2005, Meyers et al 2002, Hehl et al 1995) (See table 2.12). • Level of evidence: In total, seven RCTs were included in the two systematic reviews, which reported on specific exercise; therefore the level of evidence for specific exercises following ACL reconstruction surgery denotes level 1 evidence. • Quality of evidence: The two systematic reviews which reported on the effect of other specific exercises following ACL reconstruction each scored 5 out of 5 on the Greenhalgh critical appraisal tool, indicating high methodological quality or quality of evidence. • Relevance of evidence: Clinical outcomes, namely peak flexion, isokinetic muscle strength, quadriceps and hamstrings strength, gastrocnemius circumferences, knee joint laxity, recovery of the quadriceps muscles following ACL reconstruction, and gait retraining were reported by the three systematic reviews (Risberg et al 2004 and Wright et al 2008b) which indicates that the information retrieved from the trials were clinically relevant to patients post ACL reconstruction surgery. • Strength of evidence: Blanpied et al (2000) assessed the effectiveness of adding a slide-board home exercise program twice per week to a standard physical therapy regime (Risberg et al 2004 and Wright et al 2008b). Isometric peak extension and flexion torque, maximum lateral step height and lateral step-up repetitions to fatigue were assessed. The slide-board group demonstrated a 38% increase in knee peak isometric extension torque from pre-test values. A 2-way repeated measure ANOVA (group by test session), and posthoc testing revealed significant improvements in the slide group for quadriceps strength (101.9 +/- 31.3 N m to 140.5 +/- 31.3 N m of torque), while the control group showed no significant increase (125.1 +/- 61.7 N m to 125.8 +/- 45.1 N m of torque). Lateral step height increased significantly in the slide group from pre-test to post-test, from 22.9 +/- 5.3 cm to 28.7 +/- 5.6 cm, while the control group showed no increase (20.0 +/- 4.5 cm to 20.7 +/- 3.4 cm). Meyers et al (2002) compared stair-climbing to cycle ergometry in ACL reconstruction rehabilitation at 4 week post-operatively (Risberg et al 2004 and Wright et al 2008b). Leg girth, KT-1000 testing, isokinetic strength testing was 35.

No results found